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BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used when mechanical ventilation can no longer support oxygenation or ventilation, or if the risk of ventilator- induced lung injury is considered excessive. The optimum mechanical ventilation strategy once on ECMO is unknown. We sought to describe the practice of mechanical ventilation in children on VV-ECMO and to determine whether mechanical ventilation practices are associated with clinical outcomes. METHODS: We conducted a multicenter retrospective cohort study in 10 pediatric academic centers in the United States. Children age 14 d through 18 y on VV-ECMO from 2011 to 2016 were included. Exclusion criteria were preexisting chronic respiratory failure, primary diagnosis of asthma, cyanotic heart disease, or ECMO as a bridge to lung transplant. RESULTS: Conventional mechanical ventilation was used in about 75% of children on VV-ECMO; the remaining subjects were managed with a variety of approaches. With the exception of PEEP, there was large variation in ventilator settings. Ventilator mode and pressure settings were not associated with survival. Mean ventilator FIO2 on days 1–3 was higher in nonsurvivors than in survivors (0.5 vs 0.4, P = .009). In univariate analysis, other risk factors for mortality were female gender, higher Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS), diagnosis of cancer or stem cell transplant, and number of days intubated prior to initiation of ECMO (all P < .05). In multivariate analysis, ventilator FIO2 was significantly associated with mortality (odds ratio 1.38 for each 0.1 increase in FIO2 , 95% CI 1.09-1.75). Mortality was higher in subjects on high ventilator FIO2 (≥ 0.5) compared to low ventilator FIO2 (> 0.5) (46% vs 22%, P = .001). CONCLUSIONS: Ventilator mode and some settings vary in practice. The only ventilator setting associated with mortality was FIO2 , even after adjustment for disease severity. Ventilator FIO2 is a modifiable setting that may contribute to mortality in children on VV-ECMO. [ABSTRACT FROM AUTHOR]

Recent recommendations for wood dust sampling include sampling according to the inhalable convention of International Organization for Standardization (ISO) 7708 (1995) Air quality—particle size fraction definitions for health-related sampling. However, a specific sampling device is not mandated, and while several samplers have laboratory performance approaching theoretical for an ‘inhalable’ sampler, the best choice of sampler for wood dust is not clear. A side-by-side field study was considered the most practical test of samplers as laboratory performance tests consider overall performance based on a wider range of particle sizes than are commonly encountered in the wood products industry. Seven companies in the wood products industry of the Southeast USA (MS, KY, AL, and WV) participated in this study. The products included hardwood flooring, engineered hardwood flooring, door skins, shutter blinds, kitchen cabinets, plywood, and veneer. The samplers selected were 37-mm closed-face cassette with ACCU-CAP™, Button, CIP10-I, GSP, and Institute of Occupational Medicine. Approximately 30 of each possible pairwise combination of samplers were collected as personal sample sets. Paired samplers of the same type were used to calculate environmental variance that was then used to determine the number of pairs of samples necessary to detect any difference at a specified level of confidence. Total valid sample number was 888 (444 valid pairs). The mass concentration of wood dust ranged from 0.02 to 195 mg m−3. Geometric mean (geometric standard deviation) and arithmetic mean (standard deviation) of wood dust were 0.98 mg m−3 (3.06) and 2.12 mg m−3 (7.74), respectively. One percent of the samples exceeded 15 mg m−3, 6% exceeded 5 mg m−3, and 48% exceeded 1 mg m−3. The number of collected pairs is generally appropriate to detect a 35% difference when outliers (negative mass loadings) are removed. Statistical evaluation of the nonsimilar sampler pair results produced a finding of no significant difference between any pairing of sampler type. A practical consideration for sampling in the USA is that the ACCU-CAP™ is similar to the sampler currently used by the Occupational Safety and Health Administration for purposes of demonstrating compliance with its permissible exposure limit for wood dust, which is the same as for Particles Not Otherwise Regulated, also known as inert dust or nuisance dust (Method PV2121). [ABSTRACT FROM PUBLISHER]

The COVID-19 pandemic led to severe disruptions in health care and a relaxation of rules surrounding opioid prescribing-changes which led to concerns about increased reliance on opioids for chronic pain and a resurgence of opioid-related harms. Although some studies found that opioid prescriptions increased in the first 6 months of the pandemic, we know little about the longer-term effects of the pandemic on opioid prescriptions. Further, despite the prevalence of pain in veterans, we know little about patterns of opioid prescriptions in the Veterans Health Administration (VA) associated with the pandemic. Using a retrospective cohort of VA patients with chronic low-back pain, we examined the proportion of patients with an opioid prescription and mean morphine milligram equivalents over a 3-year period-1 year prior to and 2 years after the pandemic's onset. Analyses revealed that both measures fell during the entire observation period. The largest decrease in the odds of filling an opioid prescription occurred in the first quarter of the pandemic, but this downward trend continued throughout the observation period, albeit at a slower pace. Clinically meaningful differences in opioid prescriptions and dose over time did not emerge based on patient race or rurality; however, differences emerged between female and male veterans, with decreases in opioid prescriptions slowing more markedly for women after the pandemic onset. These findings suggest that the pandemic was not associated with short- or long-term increases in opioid prescriptions or doses in the VA. PERSPECTIVE: This article examines opioid prescribing over a 3-year period-1 year prior to and 2 years after the onset of the COVID-19 pandemic-for VA patients with chronic low-back pain. Results indicate that, despite disruptions to health care, opioid prescriptions and doses decreased over the entire observation period., (Published by Elsevier Inc.)

Objective: Little is known about why neonatology fellows pick the fellowship program they do. Understanding why fellows choose neonatology and rank their programs would be of benefit to program leadership and to other applicants., Study Design: This was a survey study sent to current neonatology fellows in the United States between September 2020 and October 2020, and were asked to rank their choices on a Likert scale. Respondents were also able to give free text responses to open-ended questions., Results: The most important factor fellows state for choosing their program was location, with multiple reasons given. There were significant differences in how certain subgroups ranked programs., Conclusion: Location of the fellowship program is the most important factor for fellows. There are differences within subgroups of fellows on how they rank their fellowship program. Fellowship directors can use this information to better inform selections on who to interview and how to rank fellows., Key Points: · Patient population appears to be the most important reason why fellows choose neonatology.. · Program location is the most important reason why fellows choose their specific training program.. · Fellowships can continue to highlight fellow camaraderie, scholarship, and clinical opportunities.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Research from across the United States has shown that rurality is associated with worse melanoma outcomes. In Indiana, nearly a quarter of all residents live in rural counties and an estimated 2180 cases of melanoma will be diagnosed in 2023., Aims: This study examines how geographical location affects the stage of melanoma diagnosis in Indiana, aiming to identify and address rural health disparities to ultimately ensure equitable care., Methods and Results: Demographics and disease characteristics of patients diagnosed with melanoma at Indiana University Health from January 2017 to September 2022 were compared using Students t-tests, Wilcoxon tests, chi-squared or Fisher's exact tests. Patients from rural areas presented with more pathological stage T3 melanomas (15.0% vs. 3.5%, p < 0.001) in contrast to their urban counterparts. Additionally, rural patients presented with fewer clinical stage I melanomas (80.8% vs. 89.3%) and more clinical stage II melanomas (19.2% vs. 8.1%), compared to urban patients, with no stage III (p = 0.028). Concerningly, a significantly higher percentage of the rural group (40.7%) had a personal history of BCC compared to the urban group (22.6%) (p = 0.005) and fewer rural patients (78.0%) compared to urban patients (89.4%) received surgical treatment (p = 0.016)., Conclusion: Patients from rural counties in Indiana have higher pathological and clinical stage melanoma at diagnosis compared to patients from urban counties. Additionally fewer rural patients receive surgical treatment and may be at higher risk of developing subsequent melanomas., (© 2024 The Authors. Cancer Reports published by Wiley Periodicals LLC.)

Background: Lung cancer is the leading cause of cancer death for both men and women in the United States. The National Lung Screening Trial (NLST) demonstrated that low-dose computed tomography (LDCT) screening can reduce lung cancer mortality among high-risk individuals, but uptake of lung screening remains low. Social media platforms have the potential to reach a large number of people, including those who are at high risk for lung cancer but who may not be aware of or have access to lung screening., Methods: This paper discusses the protocol for a randomized controlled trial (RCT) that leverages FBTA to reach screening-eligible individuals in the community at large and intervene with a public-facing, tailored health communication intervention (LungTalk) to increase awareness of, and knowledge about, lung screening., Discussion: This study will provide important information to inform the ability to refine implementation processes for national population efforts to scale a public-facing health communication focused intervention using social media to increase screening uptake of appropriate, high-risk individuals., Trial Registration: The trial is registered at clinicaltrials.gov (#NCT05824273)., (© 2023. The Author(s).)

Background: Despite reliable evidence-based research supporting the COVID-19 vaccines, population-wide confidence and trust remain limited. We sought to expand prior knowledge about COVID-19 vaccine perceptions, while determining which population groups are at greatest risk for not getting a vaccine., Methods: Study participants in the U.S. (79% female, median age group 46-60 years) were recruited through an online Qualtrics survey distributed as a Facebook advertisement from 3/19/21-4/30/21. We assumed that every participant is at risk of COVID-19 infection and should be able to get the vaccine with proper access. Bivariate and multivariable models were performed. Collinearity between variables was assessed., Results: A total of 2,626 responses were generated and 2,259 were included in data analysis. According to our multivariate model analysis, vaccines were perceived as safe by those who had or planned to obtain full vaccination (adjusted odds ratio (aOR) (95% confidence interval) = 40.0 (19.0, 84.2); p< 0.0001) and those who indicated trust in science (aOR = 10.5 (5.1, 21.8); p< 0.0001); vaccines were perceived as not safe by those who self-identified as Republicans vs. self-identified Democrats (aOR = 0.2 (0.1, 0.5); p = 0.0020) and those with high school or lower education (aOR = 0.2 (0.1, 0.4); p = 0.0007). Similarly, according to our multivariate model analysis, the following groups were most likely to reject vaccination based on belief in vaccinations: those with lower income (aOR = 0.8 (0.6, 0.9); p = 0.0106), those who do not know anyone who had been vaccinated (aOR = 0.1 (0.1, 0.4); p< 0.0001), those who are unwilling to get vaccinated even if family and friends had done so (aOR = 0.1 (<0.1, 0.2); p< 0.0001), those who did not trust science (aOR < 0.1 (<0.1, 0.1); p< 0.0001), those who believe that vaccination was unnecessary if others had already been vaccinated (aOR = 2.8 (1.5, 5.1); p = 0.0007), and those who indicate refusal to vaccinate to help others (aOR = 0.1 (0.1, 0.2); p< 0.0001). An alpha of p<0.05 was used for all tests., Conclusion: Level of education and partisanship, but not race/ethnicity, were the most likely factors associated with vaccine hesitancy or likelihood to vaccinate. Also, low vaccination rates among underrepresented minorities may be due to distrust for healthcare industries. Population sub-groups less likely to be vaccinated and/or receptive to vaccines should be targeted for vaccine education and incentives., Competing Interests: The authors have declared that no competing interests exist.

Background: Seriously ill patients admitted to the Intensive Care Unit (ICU) experience severe spiritual and existential distress. Patients' surrogate decision makers face the burden of making complex decisions about their loved ones' care. Experienced chaplains may play a role in assisting with decision-making, possibly by aligning patients' values and wishes with treatment plans and avoiding non-beneficial aggressive measures., Objectives: To identify associations between chaplaincy care and length of stay (LOS) in the medical ICU (MICU)., Methods: This was a retrospective observational study of usual spiritual care in the adult MICUs of 4 medical centers in the United States over a 3-month period. Inclusion criteria were death in the MICU or discharge to palliative care or hospice. Measures included medical, treatment, and spiritual care information. Through bivariate and multivariable analyses associations between spiritual care and LOS were examined., Results: In multivariable analysis of the 254 patients, receiving spiritual care was associated with an increased likelihood of being in a higher LOS tertile (adjusted odds ratio = 2.94, p < .001). In post hoc bivariate analysis, cases receiving spiritual care within the first 48 hours of MICU admission revealed a trend toward lower LOS (p = .181)., Conclusion: Spiritual care in the MICU was associated with longer LOS. Early intervention by chaplains who are well-integrated in the ICU may assist patients and their loved ones in coming to terms with grave illness and making difficult treatment decisions. Further well-designed studies of spiritual care interventions that may affect outcomes are needed.

Objective/background: Behavioral Sleep Interventions (BSI) is an efficacious class of treatment approaches for infant sleep disturbance. Little is known about BSI implementation in the real world. Objectives were to a) examine the prevalence of BSI implementation and related factors in a diverse sample of US mothers; b) assess racial-ethnic group differences; and c) examine predictors of BSI implementation., Participants: Participants included mothers ( n = 353) with an infant (6-18 months) from one of the three racial-ethnic groups: White Hispanic ( n = 113), White non-Hispanic ( n = 122), Black non-Hispanic ( n = 118)., Methods: Respondents completed an online survey assessing BSI implementation, familiarity, barriers, sleep knowledge, cognitions, and sleep patterns., Results: Approximately one-third (36%) of the sample endorsed BSI implementation and 59% reported BSI familiarity. Black non-Hispanic mothers were more likely to report stopping a BSI prior to completion (OR = 4.92, p <.05) and more likely to hear about BSI from a health-care professional (OR = 1.32, p <.05) compared to White non-Hispanic mothers. Racial-ethnic group differences were identified for a variety of sleep practices, including bedsharing, independent sleep onset, and score on a validated measure of problematic sleep. No racial-ethnic group differences were found in BSI implementation, cognitions, or barriers. BSI implementation was predicted by BSI familiarity, more maternal education, and cognitions around infant self-soothing., Conclusions: Differential BSI implementation does not appear to be a major driver of sleep disparities, although Black non-Hispanic mothers who decide to implement BSI do report notably lower completion rates. Future studies should examine alternative mechanisms of sleep disparities as well as strategies to promote sleep health in diverse families.

Objective: Understanding lung cancer screening behaviour is crucial to identifying potentially modifiable factors for future intervention. Qualititative work has explored attitudes and beliefs about lung cancer screening from the perspective of the participant, but the theoretically grounded factors that influence screening-eligible individuals to screen are unknown. We tested an explanatory framework for lung cancer screening participation from the individual's perspective., Methods: Data were collected as part of a sequential explanatory mixed methods study, the quantitative component of which is reported here. A national purposive sample of 515 screening-eligible participants in the United States was recruited using Facebook-targeted advertisement. Participants completed surveys assessing constructs of the Conceptual Model for Lung Cancer Screening Participation. Path analysis was used to assess the relationships between variables., Results: Path analyses revealed that a clinician recommendation to screen, higher self-efficacy scores, and lower mistrust scores were directly associated with screening participation (p < 0.05). However, the link between screening behaviour and self-efficacy appeared to be fully mediated by fatalism, lung cancer fear, lung cancer family history, knowledge of lung cancer risk and screening, income, clinician recommendation, and social influence (p < 0.05)., Conclusions: This study found that medical mistrust, self-efficacy, and clinician recommendation were significant in the decision of whether to screen for lung cancer. These findings offer insight into potentially modifiable targets most appropriate on which to intervene. This understanding is critical to design meaningful clinician- and patient-focused interventions.

Background: Patients with Alzheimer's disease and related dementias (ADRD) and traumatic brain injury (TBI) and their caregivers require cognitive and behavioral symptom management, interdisciplinary care, support for caregivers, and seamless care coordination between providers. Caring for someone with ADRD or TBI is associated with higher rates of psychological morbidity and burden, social isolation, financial hardship, and deterioration of physical health. Tremendous need exists for primary care-based interventions that concurrently address the care needs of dyads and aim to improve care and outcomes for both individuals with ADRD and TBI and their family caregivers., Methods: The Aging Brain Care Acquiring New Skills While Enhancing Remaining Strengths (ABC ANSWERS) study is a randomized controlled trial that tests the effectiveness of an intervention based on two evidence-based programs that have been developed for and previously tested in populations with ADRD, TBI, stroke, and late-life depression and/or who have survived an intensive care unit stay. This study includes 200 dyads comprised of a veteran with a diagnosis of ADRD or TBI and the veteran's primary informal caregiver. Dyads are randomized to receive the ABC ANSWERS intervention or routine Veterans Health Administration (VHA) primary care with a standardized educational and resource information packet. Data collection occurs at baseline and three follow-up time points (3 months, 6 months, and 12 months). The primary outcome is caregiver quality of life (QoL). A secondary measure for the caregiver is caregiver burden. Secondary measures for both the veteran and caregiver include symptoms of depression and anxiety., Discussion: The ABC ANSWERS intervention integrates common features of an evidence-based collaborative care model for brain health while concurrently attending to the implementation barriers of delivering care and skills to dyads. We hypothesize that caregivers in dyads randomized to the ABC ANSWERS program will experience higher levels of QoL and lower levels of depression, anxiety, dyadic strain, and caregiver burden at 12 months than those receiving usual VHA primary care., Trial Registration: ClinicalTrials.gov, NCT03397667. Registered on 12 January 2018.

: Heightened systemic inflammation contributes to cardiovascular (CVD) events in people living with HIV (PLWH), although not all PLWH develop CVD, thus suggesting a genetic modifying role. We examined GCH1 polymorphisms, which have been associated with reduced endothelial function in European populations with CVD and increased inflammation, in a racially diverse cohort of US PLWH initiating antiretroviral therapy (ART). GCH1 polymorphisms differed by race and were not associated with flow-mediated dilation or carotid intima-media thickness before or after 48 weeks of ART.

When life-sustaining treatments (LST) are no longer effective or consistent with patient preferences, limitations may be set so that LSTs are withdrawn or withheld from the patient. Many studies have examined the frequency of limitations of LST in intensive care unit (ICU) settings in the past 30 years. This systematic review describes variation and patient characteristics associated with limitations of LST in critically ill patients in all types of ICUs in the United States. A comprehensive search of the literature was performed by a medical librarian between December 2014 and April 2017. A total of 1,882 unique titles and abstracts were reviewed, 113 were selected for article review, and 36 studies were fully reviewed. Patient factors associated with an increased likelihood of limiting LST included white race, older age, female sex, poor preadmission functional status, multiple comorbidities, and worse illness severity score. Based on several large, multicenter studies, there was a trend toward a higher frequency of limitation of LST over time. However, there is large variability between ICUs in the proportion of patients with limitations and on the proportion of deaths preceded by a limitation. Increases in the frequency of limitations of LST over time suggests changing attitudes about aggressive end-of-life-care. Limitations are more common for patients with worse premorbid health and greater ICU illness severity. While some differences in the frequency of limitations of LST may be explained by personal factors such as race, there is unexplained wide variability between units.

Objective: Describe the implementation and effects of Mobile Acute Care for Elders (MACE) consultation at a Veterans Affairs Medical Center (VAMC)., Design: Retrospective cohort analysis., Intervention: Veterans aged 65 or older who were admitted to the medicine service between October 1, 2012, and September 30, 2014, were screened for geriatric syndromes via review of medical records within 48 hours of admission. If the screen was positive, the MACE team offered the admitting team a same-day consultation involving comprehensive geriatric assessment and ongoing collaboration with the admitting team and supportive services to implement patient-centric recommendations for geriatric syndromes., Results: Veterans seen by MACE (n = 421) were compared with those with positive screens but without consultation (n = 372). The two groups did not significantly differ in age, comorbidity, sex, or race. All outcomes (30-day readmission, 30-day mortality, readmission costs) were in the expected direction for patients receiving MACE but did not reach statistical significance. Patients receiving MACE had lower odds of 30-day readmission (11.9% vs 14.8%; odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.54-1.25; p = .360) and 30-day mortality (5.5% vs 8.6%; OR = 0.64; CI = 0.36-1.12; p = .115), and they had lower 30-day readmission costs (MACE $15,502; CI = $12,242-$19,631; comparison = $18,335; CI = $14,641-$22,962; p = .316) than those who did not receive MACE after adjusting for age and Charlson Comorbidity Index., Conclusion: Our MACE consultation model for older veterans with geriatric syndromes leverages the limited supply of clinicians with expertise in geriatrics. Although not statistically significant in this study of 793 subjects, MACE patients had lower odds of 30-day readmission and mortality, and lower readmission costs. J Am Geriatr Soc 67:818-824, 2019., (© 2018 The American Geriatrics Society.)

Background & Aims: In older individuals, there are unclear effects of lower endoscopy on incidence of colorectal cancer (CRC) and of colonoscopy on site of CRC. We investigated whether sigmoidoscopy or colonoscopy is associated with a decreased incidence of CRC in older individuals, and whether the effect of colonoscopy differs by anatomic location., Methods: We performed a case-control study using linked US Veterans Affairs and Medicare data. Cases were veterans aged 75 years or older diagnosed with CRC in fiscal year 2007. Cases were matched for age and sex to 3 individuals without a CRC diagnosis (controls). We determined the number of cases and controls who received colonoscopies or sigmoidoscopies from fiscal year 1997 to a date 6 months before the diagnosis of CRC (for cases) or to a corresponding index date (for controls). The probability of exposure was modeled using generalized linear mixed equations, adjusted for potential confounders. For the analysis of CRC risk in different anatomic locations, the proximal colon was defined as proximal to the splenic flexure., Results: We identified 623 cases and 1869 controls (mean age, 81 y; 98.7% male, 86.2% Caucasian). Among cases, 243 (39.0%) underwent any lower endoscopy (177 colonoscopies). Among controls, 978 (52.3%) underwent any lower endoscopy (758 colonoscopies). Cases were significantly less likely than controls to have undergone lower endoscopy within the preceding 10 years (adjusted odds ratio [aOR], 0.58; 95% confidence interval [CI], 0.48-0.69). This effect was significant for colonoscopy (aOR, 0.57; 95% CI, 0.47-0.70), but not sigmoidoscopy. Similar results were observed when a 5-year exposure window was applied. Colonoscopy was associated with a reduced risk of distal CRC (aOR, 0.45; 95% CI, 0.32-0.62) and proximal CRC (aOR, 0.65; 95% CI, 0.46-0.92)., Conclusions: In a study of the US Veterans Affairs and Medicare databases, lower endoscopy in the preceding 10 years was associated with a significant reduction in CRC incidence among older veterans. Colonoscopy was associated with significant reductions in distal and proximal CRC., (Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.)

The effect of using relocatable reference slides of chrysotile and amosite in asbestos fiber counting proficiency testing was examined for volunteer analysts from laboratories in the USA. Results of participation in one round have been published; two more rounds are reported here. In the first round, participants were asked to draw what they saw, allowing identification of error type by comparison to the reference. In later rounds only the number of fibers per field was reported since the number of errors per field has been shown to be a reasonable estimate of proficiency. The third round included a training exercise. The total number of participants stayed reasonably constant with some reduction over time. More restricted numbers participated from round to round. Those who dropped out had lower average scores than those that remained in the program; from 2006 to 2007 this difference was significant, but for 2007 to 2008 it was not. The overall results for amosite were generally good compared to an arbitrary proficiency score of 60, and continued to improve further over time. The results for chrysotile were better in rounds 1 and 3 than round 2, so that both attention to detail (drawing the fibers in round 1) and training (round 3) may improve performance, which is consistent with the major type of error being oversight of fine fibers. However, the results are still poor, even by round 3, and no analyst achieved a score of 60 in all three rounds. Further improvement is preferred since chrysotile is the most commonly encountered type of asbestos in the USA. Depending on the adopted score for proficiency many laboratories or analysts may be labeled as poor performers and this may be a deterrent to voluntary participation in this type of exercise, especially for those in most need of assistance. Participants have tested new relocatable reference asbestos proficiency counting slides in three rounds of chrysotile and three rounds of amosite. Performance for amosite was good. Poor performance for chrysotile appears to be improved by greater attention and training.